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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) OD
N Q r4Q.A jA0 r) ► mass. Date( -r, jQ 19 fj
City, Town
Permit #
a •`
Building - Owner ' s
AT: Location y-(o 3t,I °rwaaci Dr.- Name
�QT'EKCG Type of Occupancy:lCs(d&41d
New ❑ Renovation Replacement ❑
FIXTURES Plans
Submitted: Yes ❑ No [I
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
t 6TH FLOOR
7TH FLOOR
+ 8TH FLOOR
(Print or Type) RichaxdIs
Installing Company Name Plg.& Mg. Inc. Check One: Certificate
® Corp.
Address 79 Union Street ,Rear ❑ Partnership
Easthampton,Ma 01027
❑ Firm/Company
Business Telephone ¢13-527-0291 Name of Licensed Plumber
RICHARD A BOULANGER --- —�
I hereby certify that all of the details and information I have submitted (or entered)in above application are true and accurate to file best of oily
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent pro-
visions of the Massachusetts State Plumbing Code and Chapter 142 of the General Lays.
By .�, -�-s
Title _ Sig ature of censed Plum r
City/Town: Type of Plumbing License
�86L ----
APPROVED (OFFICE USE ONLY) License Number El Master ❑ Journeyman
VO
I lav
I SIS
Date ........!I.M!!Tch......................................1
Richard Boulanger
PlumberRI-eba.-M-La....P-t-umt-i-eg...m...................
Clarence Chickering
Owner .....................................................................................
46 Brierwood Drive
Address ...............................................................................
new Added Fixtures
.......................................................................................................